Embarking on its second year, the Medicare Part D prescription benefit is taking the lessons learned from the first 12 months and building upon its success.
"The first year, if you measure by almost all indices, went very, very well," said Jeff Nelligan, CMS director of media affairs. "We have guaranteed more than 38 million Medicare beneficiaries now have some form of prescription drug coverage."
In 2006, Nelligan said the new program enrolled 22.5 million people, 45 percent of whom did not have any form of prior prescription coverage, and resulted in 3.5 million prescriptions being filled daily. The average national monthly premium was $24 … $13 less than the original estimates of $37 per month. In total, the 2006 program costs came in at $197 billion less than estimated in 2005.
Another indicator of the program's success is measured in customer satisfaction.
"Five different independent surveys have shown beneficiary satisfaction at 80 percent," Nelligan said, adding these polls included J.D. Power and Associates, the Kaiser Family Foundation and Harris Interactive.
While the American Pharmacists Association (APhA) readily agrees the new benefit has helped patients gain access to much-needed medications, the overall satisfaction levels for the organization's membership probably wouldn't rank quite as high as that of consumers.
Kristina Lunner, acting vice president for policy and communications for APhA, said several challenges remain including prior authorizations, low and slow payments and an overall administrative burden for pharmacies.
With the new year comes a slough of new paperwork. In many cases, patients will need to have their prior authorizations renewed plus new beneficiaries will have to have all of their information entered into the pharmacy system.
"We've seen some hesitancy by the prescribers to follow through and request the prior authorization be approved by the plan," Lunner said. While prior authorization renewals are not mandatory with all plans, she said it would be helpful if prescribers could verify a patient's plan requirements to speed up the process, ultimately improving patient care.
Despite administrative frustrations, Lunner quickly pointed out the APhA membership is pleased with the benefit's end results including a mandate for medication therapy management (MTM) programming. APhA hopes to see "more robust MTM services in 2007," she said as plans move past the initial start-up considerations inherent in the 2006 launch.
While the actual MTM service may vary by plan, Lunner said it typically provides a patient with "a clinical review of their whole drug regimen." She continued, "In some cases, disease management occurs, such as with diabetes, that is more one-on-one, face-to-face counseling."
Lunner noted research data shows patients often don't have the tools to effectively manage their disease state.
"With MTM," she said, "it empowers the patient to be able to manage their healthcare more effectively."
In addition to a natural maturing of the program, Nelligan said providers and patients should expect to see more choice and expanded coverage in 2007 with approximately 423 more plans being offered and a 13 percent increase in the formulary.
"There are more plans offering coverage within the coverage gap," he added.
While the rolls are now shut for 2007 in most cases, one group still has a few weeks to make changes. Those that are currently enrolled in a Medicare Advantage plan (which is set up like an HMO or PPO and is sometimes called "Medicare Part C") and have prescription drug coverage with that plan have until March 31, 2007 to switch to a traditional Medicare program and select a Part D carrier. For patients eligible to make changes during this special enrollment period, they can do so by going online to www.medicare.gov or by calling 800-Medicare or the customer service number of their current plan.
There have been some small increases in the standard plan for 2007 compared to 2006. The initial deductible increased from $250 to $265; the initial coverage limit from $2,250 to $2,400; and the out-of-pocket threshold from $3,600 to $3,850.
What doesn't appear to be changing is the average premium cost.
"The average monthly premium was $24 last year and remains at $24 this year despite the customary healthcare inflation rate of approximately 6.5 to 9 percent," said Nelligan, noting the price freeze is an indication that competition among the various Part D plans is healthy and keeping beneficiary prices low.
On the front lines, Lunner said most pharmacists continue to see the Part D benefit as a mixed bag of opportunities and challenges.
"It's unfortunate that the administration of the program has become such a burden on pharmacists," she noted. "On the other side," Lunner continued, "the reason why pharmacists continue to work so hard is they recognize the great benefit to the patient both in terms of access to medicines and access to pharmacy services."
February 2007
